Provider Demographics
NPI:1073258786
Name:BENNETT, MICHAEL (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 RIVERWALK TER STE 250
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-5619
Mailing Address - Country:US
Mailing Address - Phone:918-998-0996
Mailing Address - Fax:918-235-9079
Practice Address - Street 1:3703 N KICKAPOO AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-1703
Practice Address - Country:US
Practice Address - Phone:405-275-0640
Practice Address - Fax:405-225-3008
Is Sole Proprietor?:No
Enumeration Date:2022-04-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK75431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice